Dr Joepaul Joy , Dr Vinitha Prasad, Dr Navya, Dr Stefy, Dr Shela, Dr C Jayakumar
Eleven year old male child, first child of a nonconsangenous parentage immunised ,developmentally normal,asthmatic on controllers presented with sand paper like rashes all over the body. Initially rashes developed on face, later progressed to all over the body . On Day 2 of illness ,he developed high grade intermittent fever associated with congestion of lips and oral cavity. He also complained of sorethroat. Child has received macrolides from local health care facility . Came to AIMS due to symptom persistence. He had history of discontinuation of ATT at the age of 1.5yrs due to transaminitis .
At the time of admission child was febrile with other vitals stable. General examination done showed flushed appearance with sandpaper rash all over the body and severely congested throat and lips. Systemic examination done was unremarkable. Following differential diagnosis were considered:
1. Kawasaki disease
2. Toxic shock syndrome
3. Staphylococcal scalded skin syndrome
4. Rubella
5. Infectious mononucleosis
6. Acute lupus erythematosis
Picture -Congested lips and Sand paper rashes over the skin
Blood investigation done showed normal counts with elevated inflammatory markers(CRP:43).
Group A Streptococcus Antigen Test from throat swab was positive.
Peripheral Smear done showed Microcytic hypochromic Anemia.
IgE done was elevated(1287 IU/ml).
LFT/RFT/URE done were normal.
Child was started on Inj Ampicillin and other supportive measures after sending blood cultures.
Xray STNL done showed marked adenoid hypertrophy obstructing >80 % of the airways.
Repeat counts done showed improving trend.
Blood culture done was sterile.
Child improved over the course of hospital stay and was discharged with hemodynamically stable vitals.
Scarlet fever
It is a diffuse erythematous eruption that generally occurs in association with pharyngitis. Development of scarlet fever rash requires prior exposure to S. pyogenes and occurs as a result of delayed type skin reactivity to pyrogenic exotoxin(erythrogenic toxin, usually types A,B,or C) produced the organism. Rash of scarlet fever is a diffuse erythema that blanches with pressure, with numerous small popular elevations, giving a “sandpaper” quality to the skin. It usually starts in the groin and armpits and is accompanied circumoral pallor and a strawberry tongue. Subseqently the rash expands rapidly to cover the trunk, followed extremities and ultimately desquamates, the palms and soles are usually spared. It often exhibits a linear petechial character in the antecubital fossae and axillary folds, known as Pastias lines. The diagnosis is establishes based upon clinical manifestations . Apart from rapid strep testing and throat culture, there is no role for additional testing.
Scarlet fever with pharyngitis can predispose to acute rheumatic fever.
Approach to treatment is same as that of streptococcal pharyngitis, no additional treatment warranted for skin rash.
Take home message: All patients with fever, rashes and erythematous lips/tongue are not Kawasaki disease.
All differentials should be considered. Detailed history taking and examination will help to narrow down to the diagnosis.